Substance addiction is a neurological disease. With effective medical and psychological treatment, patients can benefit from a “normalization” of brain activity in the affected regions.
Opiate Dependence and Its Treatment PDF Print E-mail
OPIATE DEPENDENCE AND ITS TREATMENT

By Rick Christensen, P.A., CAS
Chair, PA Health Committee


The National Household Survey for 2006 showed a huge increase in 12-20 year olds using oral opiates, Oxycontin being the number one drug of abuse in this category.  Marijuana was the number one drug of abuse.  Oxycontin scored higher than either cocaine or methamphetamines in the 12-20 age groups. Heroin was last as a drug of abuse although we are seeing an increasing number of adolescents and young adults who are smoking heroin, as the cost of heroin are down and the purity of heroin has improved.
So there is no doubt that opiate addiction in general is on the rise.

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ALL TREATMENT WORKS: THE ISSUE IS MATCHING THE PATIENT TO THE RIGHT TREATMENT.

In the year 2007 chemical dependency treatment is patient driven.
This means that even if we feel medication would be helpful, if the patient desires drug free treatment we should honor this.
Where opiates are concerned, withdrawal lasts 5-7 days.
The Addiction Specialist may employ any method to treat opiate withdrawal syndrome in order to achieve a drug free state.  They can use methadone on a sliding scale over 7-21 days.  They can employ symptomatic detox using different meds to treat different opiate withdrawal symptoms.
Suboxone, a partial opiate agonist, is also being used for opiate detox.

DETOXIFICATION IS NOT TREATMENT; IT IS A MEANS TO AN ENDPOINT WHERE A PATIENT CAN THEN GET DRUG FREE TREATMENT.

After withdrawal the patient should go for intensive out patient treatment or to a residential facility for extended treatment.  Post treatment medications may include an opiate antagonist called naloxone.  This essentially blocks the affect of a superimposed dose of an opiate if they slip, reinforcing abstinence.

Relapse rates are 95% when treating an opiate addict in a drug free mode because the brain takes about 35 weeks to return to normal.  What tells the patient their brain has not returned to normal is craving which takes place in the pleasure center in the brain called the limbic system.  Continued outside support with 12 step or other outside support and counseling, as well as naloxone, can help support abstinence.

Buprenorphine was approved 3 yrs ago as the first medication a physician could prescribe outside of a traditional drug treatment environment as a maintenance medication to treat opiate addicts.  Buprenorphine comes in 2 formulations:  Subutex and Suboxone.  Suboxone is Buprenorphine in combination with naloxone.  Both formulations are administered sublingually.  The naloxone portion of the Buprenorphine/ naloxone formulation is not active orally; if a patient injects the medication they will go into withdrawal.

The goal of Suboxone treatment is to alleviate opiate withdrawal symptoms and stop cravings so that the patient is well around the clock, which essentially gives the patient a level playing field to get counseling and outside group support.

This is thought of as long term treatment and is coupled with cognitive behavioral therapy and outside support for as long as the patient desires medication and the physician feels there is continued therapeutic benefit.  Suboxone has a high safety profile because it is a partial opiate agonist and therefore would be hard to overdose on.
The profile for the Suboxone patient is upwardly mobile, with a short addiction history and low opiate tolerance.  These are primarily oral opiate users.

This new treatment is only approved to be prescribed by a physician.  PA's and NP's may not prescribe this medication in a medical practice setting for opiate addiction treatment.

The physician is required to take an 8 hour course sponsored by The Centers for Substance Abuse treatment in Washington D.C.  The physician is then registered to use this medication.  A physician may only treat 30 patients in their private practice.  After one year they can apply to treat up to 100 patients.

The dosing range for Suboxone is 4mg to 32mg. Most patients stabilize on 16mg taken sublingually 1 x per day.

The reason most heroin addicts will not stabilize on suboxone is that it is a partial opiate agonist which means that the therapeutic benefit peaks @ 32mg of Suboxone, and 64mg would have no additive affect.  32mg of Suboxone is equivalent to 60mg of methadone.  With the therapeutic dosage range for methadone being 60mg - 120mg PO QD, it should become obvious to the reader that you would not stabilize most heroin addicts using suboxone due to continued cravings.

Methadone is a safe and very effective medication in the treatment of opiate addiction, and is considered the gold standard by which all other treatments are measured.

The proviso to the safety issue is a misunderstanding by prescribers on how methadone works.  Methadone accumulates to a steady state blood level in 7 days.  If a patient is started on 30mg of methadone and dosed at this level for 7 days, their blood level will be 7 times higher by day 7 as the methadone accumulates in their system.
There has been a dramatic increase in methadone overdose nationally, not due to prescribers in methadone clinics, but rather by pain doctors who do not understand the issues of accumulation particularly in treating pain patients with no tolerance to opiates.
There is a major education process provided by The American Society of Addiction Medicine to address this issue.

The criteria for treatment in a methadone program includes a one year history of opiate dependence, 18 years of age, and being approved by a health care professional who attests to evidence, both medically and historically, that they in fact have been dependent on an opiate for at least one year. 
Patients are started on a methadone dose between 10mg and 30mg PO, QD and titrated slowly to a dose that allows them to go to bed well, wake up well, no longer experience physical cravings and, if they slip and use, their dose of methadone will block a superimposed dose of an opiate other than methadone.

The first dose of methadone is sealed by federal standards to a limit of 30mg. An added dose of 10mg may be admistered 4 hrs later if opiate withdrawal symptoms continue.  The administration of methadone may not total more than 40mg in the first 24 hrs.
Opiate dependence is a chronic, progressive often fatal illness characterized by relapse.
We have more research related to methadone than any other medication, according to the General Accounting Office of Congress.  Some opponents of methadone say the use of methadone is simply "switching addictions."
You do not get AIDS, hepatitis C, overdose, gunshot wound or arrest from methadone.
You get that with heroin.  2.5 % of untreated IV drug users in Arizona test positive for HIV/AIDS, and 80% test positive for hepatitis C.

What you get with either methadone or Buprenorphine is well and able to get on with you're life. 

Conclusion

All treatment works.  The issue is matching the patient to treatments both they and the provider feel will help in the recovery process.  Medication assisted treatment can play an important role in this process.  There are 6 D's in prescribing medication.
The right Diagnosis, the right Drug, the right Dose for the proper Duration and when you Discontinue the medication will there be the issues of drug Dependence.

I recommend the Addiction Treatment Forum (http/:www.atforum.com) website on methadone and suboxone which covers more issues than I can address in this article.
Methadone is safe in pregnancy; breastfeeding is encouraged by The American Pediatric Association regardless of their dose of methadone.
In my next article I will address the issues and options in Alcohol treatment.
 
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